Over the years I’ve watched health care get more expensive for Connecticut families, small businesses and taxpayers. Families and employers are already feeling the squeeze from high premiums, deductibles and out-of-pocket spending.
That is why it’s crucial that Hartford gets health care policy right. When lawmakers propose legislation that would make it harder to keep billing accurate and health care costs under control, the bill does not land on an abstract “insurer.” It lands on Connecticut families and employers — both who cannot afford higher premiums right now.
I completed my medical residency and worked as a practicing physician in the state and later spent eight years inside a Connecticut-based health insurer, seeing up close how these policy choices play out in the real world. I understand why physicians are frustrated when a claim is revised downward after the fact.
No one wants more paperwork, more appeals or less predictability in reimbursement, but Senate Bill 342 is an overly broad response to a real, but narrow problem. It would limit health plans’ ability to use software tools to downcode certain evaluation and management claims.
Supporters argue this is needed to stop unfair payment reductions. The intent is certainly understandable. Still, it is important to keep perspective.
Downcoding is not something that gets applied to every physician, every day. It is typically used to address a small number of outlier billing patterns, including situations where routine patient visits are repeatedly billed as highly complex.
SB 342 responds to that targeted issue by taking away a highly effective tool used to manage inappropriate billing, and it will lead to increased costs.
Physicians deserve to know why a claim has been downcoded, and the system should be fair and transparent. Downcoding disputes should be handled quickly. If an insurer is using a prepayment claims edit unfairly, that insurer should be called out.
There will always be unique physician practices that require additional consideration, because their patients are truly sicker, and they deserve to bill more highly complex visits, but in my experience, these practices are outliers too — or, at least, they used to be.
Today, artificial intelligence is increasing billing pressure. A recent Blue Health Intelligence analysis highlights why accuracy in coding and billing matters more than ever as AI spreads through hospital documentation and coding. It’s much easier today to automate a significantly higher level of coding intensity.
When billing becomes more “complex” without a matching change in the care provided, costs rise. The same Blue Health analysis estimated that AI-driven coding trends may be tied to hundreds of millions in inpatient spending and more than a billion dollars in outpatient spending nationwide.
In other words, Connecticut is debating whether to restrict a tool used to correct questionable coding while new technology is making aggressive coding easier.
We need guardrails in place. Physicians deserve a fair process. But, SB 342 is an overcorrection and in medicine, we avoid this kind of overcorrection. We tailor the intervention to the localized problem. Connecticut should apply the same logic here.
A better approach would be to fix the fairness problem for the few without banning the tool.
SB 342 should be narrowed so it addresses improper downcoding without removing the tools needed to keep billing accurate and premiums under control.
Prepayment edits are one of the most effective means we have to ensure the level of service provided was real and control costs, and insurers should be able to use them. Removing this vital tool would make health care more expensive, at a time our families and employers simply cannot afford it.
Dr. Andrea Gelzer is CEO of Qual-IT Strategies, a health care consulting firm, and a physician-executive with payer industry expertise.
